Golden Rose Care Center
GOLDEN ROSE CARE CENTER in PASADENA, CA — inspection on September 11, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 9/11/2025 at 11:33 PM, the GACH Social Worker (GSW) stated Resident 1 was ready for discharge on [DATE]. GSW stated GACH Case Manager called the facility on 9/6/2025 and informed the MA that Resident 1 was ready to return to the facility on 9/6/2025 but was made aware that the facility does not have an available bed for Resident 1.
During a concurrent record review of the facility form titled, admission / Discharge to/ from Report, from 9/1/2025 to 9/10/2025 and interview with Registered Nurse (RN1) on 9/11/2025 at 1:39 PM, RN 1 stated the admission / Discharge to/ from Report indicated Resident 1 was discharged to GACH on 9/2/2025. RN1 also stated the facility did not follow the physician's order for 7-day bed hold because the facility had admitted a new resident in Resident 1's bed.
RN 1 stated this was the reason Resident 1 was still in GACH and could not be readmitted back to the facility.
During an interview on 9/11/2025 at 2 PM with the Administrator (ADM), the ADM stated the bed reserved for Resident 1 was no longer available because it was given to a new resident on 9/5/2025. ADM also stated that Resident 1's bed should have been reserved for Resident 1 for 7 days, which was from 9/3/2025 to 9/9/2025.
The ADM also stated the purpose of the bed hold was to reserve the same bed for 7 days to ensure the residents would have a homelike environment when ready to return to the facility anytime within that period.
The ADM further stated if the facility had saved Resident 1's bed, Resident 1 would have gone back to the same room on the day the resident was ready to return to the facility.
During a record review of the facility's Policy & Procedure (P&P) titled, Bed Hold, revised 9/1/2023, the P&P indicated, upon admission, the facility advises residents/ resident's representative in writing that the facility has a bed hold policy and will hold the resident's bed for up to 7 days if the resident is transferred to a general acute hospital.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.